On the same week the much anticipated revision of what he calls the "foundational document" of psychiatry was released, psychotherapist and author Gary Greenberg will be holding court for a hometown audience on everything he thinks is wrong with the manual, from its overreaching diagnoses of everyday human suffering as mental illness, to its tendency to overstate how much is really known about the neurological basis for psychiatric diseases.
"I straddle both worlds. I'm both on the inside and on the outside," said Greenberg, 55, who grew up near Ocean Beach Park, son of a well-known attorney and grandson of a former city mayor. Now, he and his wife and teenage son live in a woodsy setting 26 miles to the north in Scotland, but he travels to his hometown daily to counsel patients at the Bayonet Street practice he shares with three other psychotherapists.
"I don't pretend I don't have an interest in the DSM," he said, referring to the "Diagnostic and Statistical Manual of Mental Disorders," in its latest incarnation known as DSM-5. "As much as I try to minimize my involvement with the DSM, part of my livelihood still depends on it."
Because a DSM diagnosis is required when a patient is depending on insurance reimbursement to cover the costs of treatment, Greenberg basically holds his nose and, in consultation with the patient, chooses the one that seems to fit best. At the same time, he said, he is acutely aware of the DSM's "discrepancy between its authority and its soundness," particularly when it comes to categorizing and naming the myriad conditions of an organ as complex as the brain.
"The DSM is the basis on which research dollars get approved, or if you want to get a drug approved, so it ends up controlling the knowledge epistemology. It controls the questions we ask," he said.
The DSM is in its fifth incarnation since the first edition in 1952. The fifth edition was released Monday by the American Psychiatric Association after a 10-year revision process. Greenberg served as a field trials investigator for a draft version of the 992-page psychiatric bible even as he was interviewing subjects for his scathing critique. In a kind of preemptive strike before the DSM's release, Greenberg's third book, "The Book of Woe: The DSM and the Unmaking of Psychiatry" hit the bookstores earlier this spring.
Tonight at the Monte Cristo Bookstore in downtown New London, Greenberg will talk about his book, his ninth appearance in a coast-to-coast book tour. Thus far, he said, he's drawn audiences mostly of people "who have a real animus" toward psychiatry and "wanted me to be even more strident.
"I'm not in the middle, but I'm not as far toward the anti-psychiatry spectrum as people wanted me to be," he said, also the author of numerous articles about the failings of the mental health industry in The New York Times, the New Yorker, Wired and other publications. In the late 1990s, he began corresponding with Ted Kaczynski, "the Unabomber," an exchange that culminated in a magazine essay.
Greenberg said he felt compelled to take on the topic of the DSM-5 and the ungainly revision process it underwent, which he said turned into "a civil war in psychiatry." Along the way, he encountered "institutional defensiveness" at the APA, a reflection, he believes, of psychiatry's longstanding battle for credibility.
"Some people, perhaps many people, have benefitted from psychiatry, but not enough, and nobody understands why," he said. "When a drug or treatment is successful, no one knows why they were."
Hardly an obscure tome that collects dust on bookshelves of professional offices, the DSM is widely used by psychologists, counselors, nurses, occupational and rehabilitation therapists, social workers, attorneys and many others, and its influence over everyday people's lives can be significant. Including a new diagnostic condition in the manual, Greenberg believes, can be like offering "red meat" to pharmaceutical companies looking to develop new drugs to match.
As an example, he cites bipolar disorder in children, a new diagnosis in the DSM IV that he believes led to the overuse of powerful psychiatric drugs whose effects on developing children's brains aren't well understood.
"We're definitely taking a lot of psychiatric drugs, and we really don't understand the long-term effects, and some of these have side effects that are substantial," he said. "But I'm all for doing what people have to do to feel better. Psychiatric drugs do work sometimes, but there's no predicting it."
Greenberg advocates an approach to mental health treatment that acknowledges the uncertainties and is built on relationships of honesty and directness.
"Piety," he said, and "false certainty" are what frustrate him most. As for the DSM, he said, an argument can be made that it provides a necessary common language for understanding the workings of the human mind. But he believes it's gone too far, noting that the document started out with 22 diagnostic conditions that over the years have grown to 220, from "obsessive-compulsive and related disorders" to "feeding and eating disorders" to "opioid-related disorders" and, until 1973, included homosexuality as a mental illness.
"If they focused on just the 22 conditions and put more resources into it, it would be more effective, and concentrated on the people who need it most," Greenberg said.